Strictly-posterior thoracotomy: a minimal-access approach for construction of the modified Blalock-Taussig shunt in West African children

Introduction

In resource-poor settings, the modified Blalock-Taussig shunt (MBTS) is often performed for symptomatic relief of Fallot's tetralogy. From September 2011, we adopted the strictly posterior thoracotomy (SPOT), a minimal-access technique for the MBTS and report the cosmetic advantages in this communication.

Methods

We retrospectively analyzed the records of consecutive patients in whom the SPOT approach was used to construct the MBTS. Study end-points were early mortality, improvement in peripheral oxygenation, morbidity, and the cosmetic appeal.

Results

Between September 2011 and January 2013, 15 males and 8 females, median age 4 years (1.3 - 17 years) and weight 13 kg (11 - 54 kg) underwent the MBTS through the SPOT approach. The polytetrafluoroethylene grafts used ranged from sizes 4 - 6mm (median 5mm). The median preoperative SpO2 was 74% (55% - 78%), increasing to a postoperative median value of 84% (80% - 92%). Shunts were right-sided in 22 patients and left-sided in one. There were no shunt failures. Hospital stay ranged from 7 - 10 days. There was one early death (4.3%), and two postoperative complications (re-exploration for bleeding and readmission for drainage of pleural effusion). The surgical scars had excellent cosmetic appeal: they ranged from 5-10 cm in length; all were entirely posterior and imperceptible to the patient.

Conclusion

The SPOT approach represents a safe and cosmetically superior alternative to the standard posterolateral thoracotomy, the scar being imperceptible to the patient. The excellent cosmetic appeal and preservation of body image makes this approach particularly attractive in children and young adults.

MTHFR rs1801133 C>T polymorphism is associated with an increased risk of tetralogy of Fallot

Abnormal folate metabolism and common variants of folate-metabolizing enzymes have been described as possible risk factors for congenital heart disease (CHD). Two important folate-metabolizing enzymes involved in the folate/homocysteine metabolic pathway are 5,10-methylenetetrahydrofolate reductase (MTHFR) and methylenetetrahydrofolate dehydrogenase 1 (MTHFD1). MTHFR and MTHFD1 polymorphisms may be associated with CHD susceptibility. To evaluate the impact of MTHFR and MTHFD1 single-nucleotide polymorphisms (SNPs) on CHD susceptibility, we genotyped functional MTHFR SNPs rs1801133 C>T, rs1801131 A>C and rs2274976 G>A, and MTHFD SNPs rs2236225 C>T, rs1950902 G>A and rs1076991 A>G in a hospital-based case-control study of 173 tetralogy of Fallot (TOF) cases and 207 non-CHD controls. When MTHFR rs1801133 CC homozygote genotype was used as the reference group, the TT genotype was associated with a significantly increased risk for TOF [TT vs. CC: odds ratio (OR)=1.67; 95% confidence interval (CI): 1.01-2.75; P=0.046]. In the recessive model, when MTHFR rs1801133 CC/CT genotype was used as the reference group, the TT homozygote genotype was associated with a significantly increased risk for TOF (OR=1.81, 95% CI: 1.15-2.84; P=0.010). In conclusion, our findings suggest that MTHFR rs1801133 C>T polymorphism may play a role in susceptibility for TOF. Large-scale studies with a more rigorous study design including diverse ethnic populations are required to confirm these findings.

Imaging findings in uncorrected tetralogy of Fallot and pulmonary atresia with major aortopulmonary collateral arteries and septic embolism

Tetralogy of Fallot (TOF) is one of the most common congenital heart malformations comprising a ventricular septal defect, right ventricular outflow tract obstruction, right ventricular hypertrophy, and overriding aorta. A rare variant includes pulmonary atresia and major aortopulmonary collateral arteries. Altered hemodynamics within the functional single-ventricle results in turbulent flow and predisposes to endocardial vegetation formation which may consequently lead to thromboembolic events. We present a rare case of an adult survivor of uncorrected TOF with pulmonary atresia.

Lung decortication and lobectomy in a child with unrepaired tetralogy of fallot

Patients with uncorrected tetralogy of Fallot (TOF) have been reported as undergoing emergency noncardiac surgeries such as cesarean section, brain abscess drainage, and major abdominal surgery. The uncorrected TOF group presents a great challenge with issues related to long-term effects of chronic hypoxemia and decreased pulmonary blood flow modifying patient physiology. We report a rare case of a child with uncorrected TOF with necrotizing streptococcal pneumonia complicated by empyema and bronchopleural fistula. The child successfully underwent lung decortication and right middle lobectomy in the first stage followed by an intracardiac repair (ICR) 15 days later. This staged approach was directed at controlling the infective focus, improving the pulmonary status, and following it up with a definitive ICR electively.

Impact of transcatheter pulmonary valve replacement on biventricular strain and synchrony assessed by cardiac magnetic resonance feature tracking

BACKGROUND

Transcatheter pulmonary valve (TPV) replacement is an emerging therapy intended to restore pulmonary valve function in patients with right ventricular outflow tract conduit dysfunction; the impact of this technique on ventricular strain and synchrony is not known.

METHODS AND RESULTS

Cardiac magnetic resonance and ECG data acquired at 1 center as part of the US Melody TPV trial were analyzed. Biventricular strain and mechanical synchrony measurements were made based on short-axis and 4-chamber steady-state free precession images using feature tracking software. Post- versus pre-TPV replacement findings were compared for all patients (n=31) and subgroups with predominant pulmonary regurgitation (n=13) or stenosis (n=18). Most patients had tetralogy of Fallot (18/31). After TPV replacement, left ventricular (LV) circumferential strain increased for the whole cohort (P<0.001) and both subgroups (pulmonary regurgitation P=0.01; pulmonary stenosis P=0.02). LV longitudinal strain increased for the whole cohort (P=0.02) and pulmonary regurgitation subgroup (P=0.05); circumferential right ventricular strain increased for the pulmonary stenosis group only (P=0.05). LV longitudinal synchrony improved significantly in the pulmonary regurgitation group (maximum wall delay P=0.03; cross-correlation delay P=0.01). Electric measures of synchrony did not improve.

CONCLUSIONS

In patients with right ventricular outflow tract conduit dysfunction, TPV replacement is associated with improved global LV strain, as well as improved right ventricular strain and LV synchrony in subgroups. Given the associations between strain and synchrony and clinical outcomes, these findings support potential long-term benefits of TPV replacement.

Prosthetic reconstruction of bicuspid pulmonary valve in tetralogy of Fallot

BACKGROUND

Various techniques have been described for preserving pulmonary valve function in tetralogy of Fallot repair. In selected substrates, the pulmonary valve can be bicuspidized and preserved using polytetrafluoroethylene pericardial membrane.

METHODS

This study was a retrospective review of 20 patients aged 11 months to 31 years with tetralogy of Fallot and a bicuspid pulmonary valve (with anteroposterior cusps) who underwent intracardiac repair from August 2010 to January 2013. The anterior cusp was augmented using polytetrafluoroethylene pericardial membrane to preserve the valve hinge. A transannular patch was used in all cases. Data relating to surgical outcome, intensive care unit course, pulmonary regurgitation, and right ventricular outflow tract gradient were collected.

RESULTS

There was no mortality. Predischarge pulmonary regurgitation was ≤grade 2 in 18 (90%) patients. One patient had an outflow gradient >40 mm Hg. On follow-up of 3-24 months, there was no increase in outflow gradient; 18.7% had progression of pulmonary regurgitation.

CONCLUSION

In selected substrates, this technique is associated with minimization of pulmonary regurgitation and an excellent functional outcome. The utility of this technique needs to be validated over a longer time scale in a larger series.

Accuracy of the all patient refined diagnosis related groups classification system in congenital heart surgery

BACKGROUND

Administrative data are increasingly used to evaluate clinical outcomes and quality of care in pediatric congenital heart surgery (CHS) programs. Several published analyses of large pediatric administrative data sets have relied on the All Patient Refined Diagnosis Related Groups (APR-DRG, version 24) diagnostic classification system. The accuracy of this classification system for patients undergoing CHS is unclear.

METHODS

We performed a retrospective cohort study of all 14,098 patients 0 to 5 years of age undergoing any of six selected congenital heart operations, ranging in complexity from isolated closure of a ventricular septal defect to single-ventricle palliation, at 40 tertiary-care pediatric centers in the Pediatric Health Information Systems database between 2007 and 2010. Assigned APR-DRGs (cardiac versus noncardiac) were compared using χ2 or Fisher's exact tests between those patients admitted during the first day of life versus later and between those receiving extracorporeal membrane oxygenation support versus those not. Recursive partitioning was used to assess the greatest determinants of APR-DRG type in the model.

RESULTS

Every patient admitted on day 1 of life was assigned to a noncardiac APR-DRG (p<0.001 for each procedure). Similarly, use of extracorporeal membrane oxygenation was highly associated with misclassification of CHS patients into a noncardiac APR-DRG (p<0.001 for each procedure). Cases misclassified into a noncardiac APR-DRG experienced a significantly increased mortality (p<0.001).

CONCLUSIONS

In classifying patients undergoing CHS, APR-DRG coding has systematic misclassifications, which may result in inaccurate reporting of CHS case volumes and mortality.

Surgical management of tetralogy of fallot: in defense of the infundibulum

Surgical treatment of the Tetralogy of Fallot (ToF) is one of the great successes of medicine and also a topic of controversy. Different strategies have been proposed, including age-based (neonatal) management strategies as well as anatomic-based management strategies. Regardless of the management strategy entailed, the surgical management of ToF has considerably evolved over the years. As a result, patients can now expect excellent early results with survival approaching 100% for those without genetic syndromes. The goals of current surgical therapy should be to mitigate the late right ventricular (RV) dysfunction that may occur by minimizing the extent of surgical injury during the intial repair. As the surgical techniques continue to advance, the outcomes will continue to improve.

Poorer right ventricular systolic function and exercise capacity in women after repair of tetralogy of fallot: a sex comparison of standard deviation scores based on sex-specific reference values in healthy control subjects

BACKGROUND

In repaired congenital heart disease, there is increasing evidence of sex differences in cardiac remodeling, but there is a lack of comparable data for specific congenital heart defects such as in repaired tetralogy of Fallot.

METHODS AND RESULTS

In a prospective multicenter study, a cohort of 272 contemporary patients (158 men; mean age, 14.3±3.3 years [range, 8-20 years]) with repaired tetralogy of Fallot underwent cardiac magnetic resonance for ventricular function and metabolic exercise testing. All data were transformed to standard deviation scores according to the Lambda-Mu-Sigma method by relating individual values to their respective 50th percentile (standard deviation score, 0) in sex-specific healthy control subjects. No sex differences were observed in age at repair, type of repair conducted, or overall hemodynamic results. Relative to sex-specific controls, repaired tetralogy of Fallot in women had larger right ventricular end-systolic volumes (standard deviation scores: women, 4.35; men, 3.25; P=0.001), lower right ventricular ejection fraction (women, -2.83; men, -2.12; P=0.011), lower right ventricular muscle mass (women, 1.58; men 2.45; P=0.001), poorer peak oxygen uptake (women, -1.65; men, -1.14; P<0.001), higher VE/VCO2 (ventilation per unit of carbon dioxide production) slopes (women, 0.88; men 0.58; P=0.012), and reduced peak heart rate (women, -2.16; men -1.74; P=0.017). Left ventricular parameters did not differ between sexes.

CONCLUSIONS

Relative to their respective sex-specific healthy control subjects, derived standard deviation scores in repaired tetralogy of Fallot suggest that women perform poorer than men in terms of right ventricular systolic function as tested by cardiac magnetic resonance and exercise capacity. This effect cannot be explained by selection bias. Further outcome data are required from longitudinal cohort studies.

Abnormal agitated saline study results after tetralogy of Fallot repair

Residual intracardiac or extracardiac shunting is frequently seen in patients with repaired congenital heart disease and can cause systemic hypoxemia. We present the case of an adult with tetralogy of Fallot who underwent two corrective surgical procedures as a child with subsequent pulmonary valve replacement due to residual pulmonary insufficiency. Further details of her operative history were otherwise unknown. After being lost to follow-up for many years, she presented with unexplained cyanosis and a markedly abnormal agitated saline study on transthoracic echocardiography in which only the left heart filled after contrast administration. We review the differential diagnosis for such a presentation and discuss the utility of cardiac magnetic resonance imaging (MRI) to define the etiology. Cardiac MRI, a frequently used imaging modality to longitudinally assess adult patients with congenital heart disease, provides excellent image quality of cardiac structures and the ability to perform angiography in a variety of imaging planes. These advantages render cardiac MRI, a useful modality to determine the etiology of unexplained cyanosis in these patients as both intracardiac and extracardiac shunts can be detected.

Cor triatriatum: an unusual cause of elevated pulmonary capillary wedge pressure in a child with tetralogy of Fallot

The coexistence of cor triatriatum and tetralogy of Fallot (TOF) is rare. Preoperative identification of cor triatriatum may be difficult owing to reduced pulmonary blood flow in patients with TOF. However, it is imperative to identify this rare combination as failure to identify obstruction to pulmonary venous egress may result in persistent pulmonary venous hypertension postoperatively. The authors discuss hemodynamic aspects of this rare coexistence in a 14-month-old child in whom pulmonary capillary wedge pressure was elevated despite right ventricular outflow obstruction.

Impact of pregnancy on the cardiac health of women with prior surgeries for pulmonary valve anomalies

OBJECTIVE

We assessed the impact of pregnancy on long-term cardiac outcomes in women with prior surgery for congenital pulmonary valve anomalies.

STUDY DESIGN

Data on all reproductive age women with prior pulmonary valve repair or replacement, cared for at a tertiary institution over a 10-year period, were analyzed. Kaplan-Meier curves and proportional hazards models were estimated to assess the impact of pregnancy and multiparity on a composite long-term adverse outcome defined as death, heart failure, or unanticipated cardiac surgery. Peripartum cardiac complications were also assessed.

RESULTS

Thirty-three parous and 20 nulliparous, nonpregnant controls with primary pulmonary valve replacement or repair were identified. Among the parous women, there were 95 pregnancies (median, 3.0; 1-10) resulting in 81 live births. Peripartum cardiac complications occurred in 28 (29.8%; 95% confidence interval, 20.4-39.2) of the pregnancies. A composite adverse long-term cardiac outcome occurred in 17 of 33 parous women, over 417 person-years (4 per 100 person-years) and 1 of 20 nulliparous women over 258 person-years (0.4 per 100 person-years); women with pregnancies were more likely at any point in time to have a composite long-term adverse cardiac outcome compared with nulliparous controls. Women with 2 or more pregnancies were more likely to have a composite adverse cardiac outcome than those with less than 2 pregnancies (hazard ratio, 8.8; 95% confidence interval, 1.5-50.3).

CONCLUSION

Peripartum cardiac complications are common in women with prior pulmonary valve repair or replacement. Pregnancy appears to increase the risk of long-term adverse cardiac outcomes in these patients when compared with nulliparous controls.

Exercise in children with common congenital heart lesions: balancing benefits with risks

Children with corrected common congenital heart lesions are often withheld from regular exercise by their parents. While there are some modest risks with exercise, they should be seen in perspective, and the life-long benefits of regular exercise on general health, mood and well-being should be emphasised.

Building quality indicators to improve care for adults with congenital heart disease

OBJECTIVES

This study sought to develop quality indicators (QIs) for outpatient management of adult congenital heart disease (ACHD) patients.

BACKGROUND

There are no published QIs to promote quality measurement and improvement for ACHD patients.

METHODS

Working groups of ACHD experts reviewed published data and United States, Canadian, and European guidelines to identify candidate QIs. For each QI, we specified a numerator, denominator, period of assessment, and data source. We submitted the QIs to a 9-member panel of international ACHD experts. The panel rated the QIs for validity and feasibility in 2 rounds on a scale of 1 to 9 using the RAND/University of California-Los Angeles modified-Delphi method, and final QI selection was on the basis of median scores.

RESULTS

A total of 62 QIs were identified regarding appropriateness and timing of clinical management, testing, and test interpretation. Each QI was ascertainable from health records. After the first round of rating, 29 QIs were accepted, none were rejected, and 33 were equivocal; on the second round, 55 QIs were accepted. Final QIs included: 8 for atrial septal defects; 9 for aortic coarctation; 12 for Eisenmenger; 9 for Fontan; 9 for D-transposition of the great arteries; and 8 for tetralogy of Fallot.

CONCLUSIONS

This project resulted in development of the first set of QIs for ACHD care based on published data, guidelines, and a modified Delphi process. These QIs provide a quality of care assessment tool for 6 ACHD conditions. This rigorously designed set of QIs should facilitate measuring and improving the quality of care for this growing group of patients.

Risk of coronary artery compression among patients referred for transcatheter pulmonary valve implantation: a multicenter experience

BACKGROUND

The Melody transcatheter pulmonary valve (TPV) was approved for implantation in obstructed right ventricular outflow tract conduits in 2010 after a multicenter trial demonstrating improvements in conduit obstruction, regurgitation, and right ventricular pressure. A recognized risk and contraindication to TPV implantation is the demonstration of coronary artery (CA) compression during balloon angioplasty or stent placement in the overlying conduit. This study is the first to characterize the risk of CA compression in this population.

METHODS AND RESULTS

From 2007 to 2012, 404 patients underwent 407 catheterizations for potential TPV implantation (median age, 18 years) at 4 centers. Three hundred forty-three patients (85%) underwent valve implantation. Twenty-one patients (5%) had evidence of CA compression with simultaneous right ventricular outflow tract angioplasty and CA angiography. Sixty-eight patients (17%) had abnormal CA anatomy. Fifteen of 21 (71%) patients with CA compression had abnormal CA anatomy. Eight patients with tetralogy of Fallot and 7 patients with transposition of the great arteries demonstrated compression. Of the 34 patients with tetralogy of Fallot and abnormal CA, 7 (21%) demonstrated CA compression.

CONCLUSIONS

CA compression following TPV implantation can be catastrophic. CA compression was observed in 5% of patients during test balloon angioplasty. No patients in this study developed clinically apparent CA compression after TPV implantation. CA compression was significantly associated with the presence of abnormal CA anatomy, especially in patients with tetralogy of Fallot or transposition of the great arteries. Preimplantation coronary angiography with simultaneous test angioplasty is an important step to evaluate for the presence of CA compression during TPV implantation.

Right ventricular wall-motion changes after infant open heart surgery--a tissue Doppler study

BACKGROUND

Right ventricular (RV) dysfunction is a well-recognized complication of cardiopulmonary bypass surgery (CPB) in adults. Infants and neonates may also be at high risk for this due to immature myocardium. Conventional assessment of RV function is just qualitative, but novel tissue Doppler echocardiographic (TDI) markers including peak systolic strain rate (SR) and isovolumic contraction acceleration (IVA) permit noninvasive quantitation of RV function. This study assessed myocardial velocities, IVA and SR in infants and neonates undergoing open heart surgery using TDI to study regional myocardial function perioperatively.

METHODS

Transthoracic TDI data were obtained in the OR before and 24 hours post-CPB on 53 consecutive infants (age 0.39 ± 0.23 years). They were followed with TDI through hospital discharge.

RESULTS

Mean CPB time was 87 ± 49 min (cross-clamp 52 ± 26 min). Peak systolic (STDI ) and diastolic myocardial velocities (ETDI , ATDI ), IVA, and peak SR were recorded in RV and LV from standard views for offline analysis. Postoperatively, LV systolic function and diastolic longitudinal function were unchanged or improved from baseline. LV radial velocities were increased postoperatively indicating adequate support. In contrast, RV longitudinal systolic and diastolic function was significantly diminished after CPB. RV changes persisted through hospital discharge.

CONCLUSIONS

In infants and neonates, perioperative measurements of systolic and diastolic tissue Doppler parameters are feasible and revealed significant RV systolic and diastolic dysfunction post-CPB with preserved LV function. As such, TDI provides a sensitive tool to monitor the infant heart after CPB and may potentially be useful to assess different myocardial protection strategies.

GATA4 loss-of-function mutations underlie familial tetralogy of fallot

Tetralogy of Fallot (TOF) represents the most common form of cyanotic congenital heart disease and accounts for significant morbidity and mortality in humans. Emerging evidence has implicated genetic defects in the pathogenesis of TOF. However, TOF is genetically heterogeneous and the genetic basis for TOF in most patients remains unclear. In this study, the GATA4 gene were sequenced in 52 probands with familial TOF, and three novel heterozygous mutations, including A9P and L51V both located in the putative first transactivational domain and N285S in the C-terminal zinc finger, were identified in three probands, respectively. Genetic analysis of the pedigrees demonstrated that in each family the mutation cosegregated with TOF with complete penetrance. The missense mutations were absent in 800 control chromosomes and the altered amino acids were highly conserved evolutionarily. Functional analysis showed that the GATA4 mutants were consistently associated with diminished DNA-binding affinity and decreased transcriptional activity. Furthermore, the N285S mutation completely disrupted the physical interaction between GATA4 and TBX5. To our knowledge, this report associates GATA4 loss-of-function mutations with familial TOF for the first time, providing novel insight into the molecular mechanism involved in TOF and suggesting potential implications for the early prophylaxis and allele-specific therapy of TOF.

JAG1 mutation in a patient with deletion 22q11.2 syndrome and tetralogy of Fallot

Deletion 22q11.2 (del22q11.2) syndrome, also known as DiGeorge/Velo-cardio-facial syndrome (DG/VCFS), and Alagille syndrome are genetic disorders characteristically associated with congenital heart defects (CHDs). We report on a patient with tetralogy of Fallot (TOF) and clinical features of DG/VCFS, hemizygous for del22q11.2 and heterozygous for the 2810G > A (p.Arg937Gln) mutation in the JAG1 gene associated with Alagille syndrome. The clinical features of del22q11.2 syndrome are present in the patient, including facial anomalies, typical TOF, speech delay with hypernasal voice, and learning difficulties. TOF and mild hepatic involvement, consisting of slightly elevated aminotransferase conjugated bilirubin levels, were the only features of Alagille syndrome in our patient. The anatomic type of TOF displayed no distinctive recognizable pattern for either DG/VCFS or Alagille syndrome. It is likely that hemizygosity of the TBX1 gene was causally related to TOF in this patient, although a synergistic pathogenic role of the JAG1 gene mutation in causing the heart defect cannot be excluded. JAG1 mutations have been previously detected in patients with nonsyndromic TOF and recent molecular evidence supports the cumulative effect of multiple genetic defects in the etiology of human malformations. We hypothesize that a similar mechanism could be present in this patient with del22q11.2 syndrome associated with a JAG1 missense mutation acting as possible modifier factor for TOF.

Risk and protective factors in the origin of conotruncal defects of heart--a population-based case-control study

Congenital heart defect (CHD) cases have been evaluated together as a group in some previous epidemiological studies. However, different CHD entities have different etiologies, and the underlying causes are unclear in the vast majority of patients. Thus the aim of this study was to analyze the possible association of different maternal diseases with the risk of four types of conotruncal defects (CTD), that is, truncus arteriosus, d-transposition of the great arteries, tetralogy of Fallot, and double-outlet right ventricle based on autopsy or surgical report diagnosis. Acute and chronic diseases with related drug treatments and peri-conceptual folic acid or multivitamin supplementations were compared in mothers of 598 CTD cases, of 902 matched controls, and 38,151 population controls without any defects, and with 20,896 malformed controls with other isolated non-cardiac defects in the population-based large dataset of the Hungarian Case-Control Surveillance of Congenital Abnormalities. Mothers who had medically recorded influenza and the common cold with secondary complications in the prenatal maternity logbook during the second and/or third gestational months were associated with a higher risk of CTD (OR with 95% CI: 2.22, 1.19-3.88). The common denominator of these maternal diseases may be high fever, which could be prevented by antifever therapies. On the other hand, high doses of medically recorded folic acid in early pregnancy were able to reduce the birth prevalence of CTD (OR with 95% CI: 0.54, 0.39-0.73), and this reduction was significant in transposition of the great arteries (0.46, 0.29-0.71) as well. In conclusion, high fever related maternal diseases may have a role in the origin of CTD, while high doses of folic acid in early pregnancy were able to reduce of CTD, particularly transposition of great vessels.

Percutaneous Edwards SAPIEN(™) valve implantation for significant pulmonary regurgitation after previous surgical repair with a right ventricular outflow patch

BACKGROUND

Current indications for percutaneous pulmonary valve implantation (PPVI) are limited to patients who had their outflow tracts repaired with the use of a "full" condui-homograft. Patients after a patch repair are believed to have an unfavorable anatomy for PPVI.

OBJECTIVES

To evaluate a novel use of Edwards SAPIEN(TM) valve for percutaneous treatment of moderate and severe pulmonary regurgitation after tetralogy of Fallot (TF) repair with a right ventricular outflow (RVOT) patch.

METHODS

PPVI was intended in 10 patients (age 21-39 years, 2 ♂) with regurgitant fraction of 30-59%, measured by cardiac magnetic resonance imaging (CMRI) 16-30 years after repair with a RVOT patch. Balloon test-inflations were used for definitive measurements and location of the landing site for the valve. All RVOTs were prestented.

RESULTS

Successful valve implantation was achieved in nine patients. In one patient a bare-metal stent used for prestenting embolized into pulmonary artery. A 26-mm valve was implanted in seven and a 23-mm in two patients. CMRI at 1-2 month follow-up (n = 8) demonstrated both, sustained relief of pulmonary incompetence (regurgitant fraction = 0-14%) and significant decrease of the right ventricular end-diastolic volume indexes (from 169.9 ± 43.8 to 140.0 ± 40.3 ml/m(2) , P < 0.001). At that follow-up no adverse event occurred. No stent fractures were observed.

CONCLUSIONS

We report the first case series of patients with significant PR after a RVOT patch repair, successfully treated with a percutaneous Edwards SAPIEN(TM) valve implantation. The procedure is technically feasible and may be offered to patients with the outflow tracts larger than those limited by the Melody(®) system available currently.

Magnetic resonance angiography vs. angiography in tetralogy of Fallot

AIM

: To determine whether gadolinium-enhanced three-dimensional magnetic resonance angiography can provide a noninvasive alternative to diagnostic catheterization for evaluation of pulmonary artery anatomy in tetralogy of Fallot.

PATIENTS AND METHODS

Thirty-five consecutive patients with tetralogy of Fallot, who attended the cardiology outpatient department between January 2008 and December 2009, were included in the study. There were 21 males and 14 females, with a mean age of 9 ± 4.15 years (range, 3-21 years). Thirty-two patients had tetralogy of Fallot with varying severities of valvular and infundibular stenosis. Three patients had tetralogy of Fallot with pulmonary atresia. All patients underwent both cardiac catheterization with X-ray angiography and 3-dimensional magnetic resonance angiography within one month.

RESULTS

Measurements of right and left pulmonary arteries and aortopulmonary collaterals were equal by both methods. There was a good correlation between magnetic resonance angiography and catheterization measurements of branch pulmonary arteries.

CONCLUSION

Gadolinium-enhanced three-dimensional magnetic resonance angiography can be used as a reliable noninvasive alternative to X-ray cineangiography for delineation of pulmonary arterial anatomy in sick infants and young children, obviating the need for catheterization.

Tetralogy of Fallot with pheochromocytoma: an unusual therapeutic challenge

An adult with unoperated tetralogy of Fallot diagnosed simultaneously with pheochromocytoma is extremely rare. This poses obvious diagnostic and therapeutic challenges. A 29-year-old woman with these conditions was successfully operated on for both diseases in the same hospitalization. There is some interesting speculation regarding the association of pheochromocytoma with uncorrected cyanotic congenital heart disease.